Pneumonia, ventilator-associated (VAP): Difference between revisions

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===VAP Pathogens Excluson List===

'''NEW CDC LIST''' (does not include candida b/c can be a valid pathogen in immunocompromised pts who have candida in both blood and ETT cultures (see above ~~list of sources~~)

'''NEW CDC LIST''' (does not include candida b/c can be a valid pathogen in immunocompromised pts who have candida in both blood and ETT cultures (see list 5B, above)

*Normal respiratory flora

*Normal oral flora

*Mixed respiratory flora

*~~coagulase~~-negative staph species (includes S. epidermidis, does '''not''' include S. aureus)

*Cagulase-negative staph species (includes S. epidermidis, does '''not''' include S. aureus)

*Enterococcus species

*Blastomyces species (blasto)

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*Pneumocystis species

*Patients might be treated for infection with these pathogens, but we should still not code them as VAP. In that case you might be able to code it as a '''[[Hospital-acquired pneumonia (HAP) in ICD10]]''' or '''[[Community-acquired pneumonia (CAP) in ICD10]]'''.

*Some Notes:

**Prior colonization with MRSA does not exclude it from causing VAP, if they meet the listed criteria.

~~===MRSA colonized===~~

~~Is this still valid? It is cut and pasted below and taken from the old guidelines.{{Discussion}}~~

~~{{DiscussAllan |1. Does MRSA still not exclude?}}~~

*These patients can develop VAP if all other criteria are met and MRSA is cultured in their endotracheal secretions. They are not excluded because of previous colonization.

=== CXR's===

~~{{DiscussAllan |2. VAP missed because follow up CXR's after initial infiltrate not done. Criteria says: new~~ and ~~persistent~~ or ~~progressive~~ and ~~persistent infiltrates~~. ~~If QA team wants improved VAP recordings maybe attendings need to~~ be ~~reminded to do those follow up~~ CXR~~'s on~~ the ~~cases that they think have VAP?}}~~

*Because it is well recognized that there are many non-infectious reasons for fleeting infiltrates in intubated ICU patients, Criterion#3 above requires that the listed changes be either "New and Persistent" or "Progressive and Persistent". This necessarily means that there must be >1 CXR -- preferably over more than 1 day -- showing the "persistence".

*~~Some~~ VAP ~~can be occasionally missed because the doctors are not always doing the follow up~~ CXR's ~~after~~ the ~~intial infiltrate and identification of pathogen. If the infiltrate need to~~ be ~~new and~~ persistent ~~or progressive~~ and ~~persistent, if those follow up CXR's are not done~~ we ~~can't code~~ a ~~VAP even if it is a probable VAP~~. ~~If the QA people want~~ to ~~improve VAP recording by data collectors than maybe attendings need to be reminded to do those follow up CXR~~'s ~~on the cases that they think have VAP? Just a thought~~.~~[[User:GHall|GHall]] 10:42, 2018 April 5 (CDT){{Discussion}}~~

*If, in real time, you are seeing that a ventilated patient qualifies for a VAP ''except'' that a followup CXR wasn't done to demonstrate persistence, you should point out to the physician(s) that the CDC criterion require infiltrates be persistent by chest imaging and therefore we would require a followup CXR to confirm the diagnosis. Refer them to Dr. Garland if there's resistance to this.

===~~possible~~ option for VAP cases that cannot be confirmed===

===Possible option for VAP cases that cannot be confirmed===

*{{DiscussAllan |

*At the team meeting, Gail made a suggestion of making a category or a flag for patients that may have a VAP but lack some confirming information. (PVAP - presumed VAP) Just wondering if this is an option?--[[User:LKolesar|LKolesar]] 10:35, 2018 June 15 (CDT)}}

@@ Line 96: / Line 96: @@
 ===VAP Pathogens Excluson List===
-'''NEW CDC LIST'''  (does not include candida b/c can be a valid pathogen in immunocompromised pts who have candida in both blood and ETT cultures (see above list of sources)
+'''NEW CDC LIST'''  (does not include candida b/c can be a valid pathogen in immunocompromised pts who have candida in both blood and ETT cultures (see list 5B, above)
 *Normal respiratory flora
 *Normal oral flora
 *Mixed respiratory flora
-*coagulase-negative staph species (includes S. epidermidis, does '''not''' include S. aureus)
+*Cagulase-negative staph species (includes S. epidermidis, does '''not''' include S. aureus)
 *Enterococcus species
 *Blastomyces species (blasto)
@@ Line 109: / Line 109: @@
 *Pneumocystis species
 *Patients might be treated for infection with these pathogens, but we should still not code them as VAP. In that case you might be able to code it as a '''[[Hospital-acquired pneumonia (HAP) in ICD10]]''' or '''[[Community-acquired pneumonia (CAP) in ICD10]]'''.
+*Some Notes:
+**Prior colonization with MRSA does not exclude it from causing VAP, if they meet the listed criteria.
-===MRSA colonized===
-Is this still valid? It is cut and pasted below and taken from the old guidelines.{{Discussion}}
-{{DiscussAllan |1. Does MRSA still not exclude?}}
-*These patients can develop VAP if all other criteria are met and MRSA is cultured in their endotracheal secretions. They are not excluded because of previous colonization.
 === CXR's===
-{{DiscussAllan |2. VAP missed because follow up CXR's after initial infiltrate not done.   Criteria says: new and persistent or progressive and persistent infiltrates. If QA team wants improved VAP recordings maybe attendings need to be reminded to do those follow up CXR's on the cases that they think have VAP?}}
+*Because it is well recognized that there are many non-infectious reasons for fleeting infiltrates in intubated ICU patients, Criterion#3 above requires that the listed changes be either "New and Persistent" or "Progressive and Persistent".  This necessarily means that there must be >1 CXR -- preferably over more than 1 day -- showing the "persistence".
-*Some VAP can be occasionally missed because the doctors are not always doing the follow up CXR's after the intial infiltrate and identification of pathogen. If the infiltrate need to be new and persistent or progressive and persistent, if those follow up CXR's are not done we can't code a VAP even if it is a probable VAP. If the QA people want to improve VAP recording by data collectors than maybe attendings need to be reminded to do those follow up CXR's on the cases that they think have VAP? Just a thought.[[User:GHall|GHall]] 10:42, 2018 April 5 (CDT){{Discussion}}
+*If, in real time, you are seeing that a ventilated patient qualifies for a VAP ''except'' that a followup CXR wasn't done to demonstrate persistence, you should point out to the physician(s) that the CDC criterion require infiltrates be persistent by chest imaging and therefore we would require a followup CXR to confirm the diagnosis.  Refer them to Dr. Garland if there's resistance to this.
-===possible option for VAP cases that cannot be confirmed===
+===Possible option for VAP cases that cannot be confirmed===
 *{{DiscussAllan |
 *At the team meeting, Gail made a suggestion of making a category or a flag for patients that may have a VAP but lack some confirming information. (PVAP - presumed VAP)  Just wondering if this is an option?--[[User:LKolesar|LKolesar]] 10:35, 2018 June 15 (CDT)}}